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Coverage criteria policies

Spinal fusion, lumbar

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for lumbar spine fusion surgery for degenerative spine conditions.

Prior authorization is not required for fusion surgery of the cervical and thoracic areas of the spine.

Coverage

Lumbar spinal fusion surgery is covered per the indications listed below.

The patient is to be offered patient decision support.

This policy addresses the adult population. Spinal fusion surgery for children will be addressed on a case by case basis.

Indications that are covered without prior authorization

Lumbar fusions are considered medically necessary for spinal instability associated with any of the following conditions:

  • Epidural compression or vertebral destruction from tumor
  • Idiopathic scoliosis over 40 degrees
  • Instability after debridement for infection
  • Neural compression after spinal fracture
  • Pseudarthrosis
  • Spinal infections (including tuberculosis, osteomyelitis, discitis)
  • Acute cauda equine OR acute spinal cord compression syndrome
  • Acute spinal fracture from documented trauma.
  • Intra-operative spinal instability

Indications that require prior authorization

Lumbar fusions for patients with one or more of the following:

  • Chronic low back pain
  • Neurogenic claudication
  • Radicular pain
  • Progressive objective neurological deficit

Coverage Criteria

  1. Non-emergent spinal fusions must meet criteria A & B listed below AND the criteria listed for II, III or IV below:
    1. Patient must have an evaluation at a Designated Medical Spine Center (MSC) prior to an orthopedic spine surgeon and neurosurgeon office consultation visit for specified lumbar spine surgery conditions;
    2. The visit summary notes from the MSC must be submitted with the request;
  2. For spinal fusion surgery for degenerative conditions with spinal instability or spinal stenosis associated with:
    1. One or more of the following diagnoses:
      1. Spondylolisthesis;
      2. Spinal stenosis;
      3. Spinal stenosis decompression likely to result in iatrogenic instability (greater than 50% facet joint excision bilaterally or entire facet on one side)
      4. Scoliosis (degenerative);
      5. Post laminectomy syndrome; or
      6. Progressive objective neurological deficit.
        AND
    2. Documentation by the operating surgeon demonstrating compliance with all of the following criteria:
      1. Documented unremitting pain and disability for at least 3 months that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive therapy must include all of the following:
        1. An active, organized, and progressive strength and flexibility program;
          Conservative therapy
          must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
          Formal physical therapy
          , at least four visits over a six week course, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted.
        2. A psycho-educational component that deals with patient expectations and perceptions as well as the anatomic sources of back pain;
        3. Documentation of less than 30% improvement in the Oswestry Disability Index (ODI) or Focus On Therapeutic Outcomes (FOTO) scores between starting conservative treatment and the day a decision to have surgery is made;
        4. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still 21 - 60.
      2. Radiographic documentation (plain radiographs, MRI/CT scans) of spinal instability.
      3. Absence of untreated, underlying, contributory mental health conditions or psychological issues (including but not limited to depression, drug or alcohol abuse).
      4. If the ODI score is greater than 80% or the FOTO score is less than 20, preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes.
      5. Documentation must include ODI or FOTO scores from the first and last therapy visits prior to surgery that demonstrate less than 30% improvement and a copy of the most recent pre-surgical ODI or FOTO patient status.
      6. Documented degenerative disc disease limited to 1 to 2 disc levels, documented by appropriate diagnostic imaging as correlated with physical findings.
  3. For spinal fusion surgery for chronic (defined as lasting equal to or longer than one year) discogenic back pain alone (without instability or deformity)
    1. Documentation by the operating surgeon demonstrating compliance with all of the following criteria:
      1. Documented unremitting, discogenic pain and disability for at least 1 year that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive conservative therapy must include all of the following:
        1. An active, organized, and progressive strength and flexibility program;
          Conservative therapy
          must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
          Formal physical therapy
          , at least four visits over a six week course, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted.
        2. A psycho-educational component that deals with patient expectations and perceptions as well as the anatomic sources of back pain;
        3. Documentation of less than 30% improvement in the Oswestry Disability Index (ODI) or FOTO scores between starting conservative treatment and the day a decision to have surgery is made;
        4. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still 21 - 60.
      2. Preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes.
      3. Documentation must include ODI or FOTO scores from the first and last therapy visits prior to surgery that demonstrate less than 30% improvement and a copy of the most recent pre-surgical ODI or FOTO patient status.
      4. Documented degenerative disc disease limited to 1 to 2 disc levels, documented by appropriate diagnostic imaging as correlated with physical findings.
  4. For a repeat/revision spinal fusion surgery
    1. Documentation by the operating surgeon demonstrating compliance with all of the following criteria:
      1. Documented unremitting pain and disability for at least 6 months that is refractory to intensive conservative therapy for at least 8 weeks. The course of intensive conservative therapy must include all of the following:
        1. An active, organized, and progressive strength and flexibility program;
          Conservative therapy
          must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
          Formal physical therapy
          , at least four visits over a six week course, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted.
        2. psycho-educational component that deals with patient expectations and perceptions as well as the anatomic sources of back pain;
        3. Documentation of less that 30% improvement in the Oswestry Disability Index (ODI) or FOTO scores between starting conservative treatment and the day a decision to have surgery is made;
        4. A preoperative ODI that is still between 40% - 79% or FOTO Status Score that is still 21 - 60.
      2. Preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes;
      3. Documentation must include Oswestry Disability Index (ODI) or FOTO scores from the first and last therapy visits prior to surgery that demonstrate less than 30% improvement and a copy of the most recent pre-surgical ODI or FOTO patient status.
      4. Documented degenerative disc disease limited to 1 to 2 disc levels, documented by appropriate diagnostic imaging as correlated with physical findings.

Indications that are not covered

Lumbar fusions are not considered medically necessary or covered for the management of the following conditions:

  • With initial primary laminectomy/discectomy for nerve root decompression without documented instability;
  • Multiple-level degenerative disc disease (more than 2 disc levels);
  • Minimally invasive facet fusions;
  • Absence of an evaluation at a Designated Medical Spine Center; and
  • All other conditions not listed under “Indications that are covered”

Lumbar fusions with any of the following devices or techniques are not covered because the following are considered experimental or investigational:

  • Anterior interbody fusion or implantation of intervertebral body fusion devices using a laparoscopic approach;
  • Axial interbody approach (AxiaLif®);
  • Dynamic spine stabilization device systems (e.g., Dynesys®, Stabilimax NZ®);
  • Interspinous Process Decompression to treat spinal stenosis (e.g., X-STOP®);
  • Stand alone Spire™ plate for fusion

Definitions

Cauda equina - A bundle of spinal nerve roots which arise from the termination of the spinal cord proper, it comprises the roots of all the spinal nerves below the first lumbar (L1).

Designated Medical Spine Center – is a clinic with medical spine specialists whose focus is on the non-surgical, comprehensive management of spine, neck and back problems using a biopsychosocial active re-conditioning model. A Designated Medical Spine Center has shown a commitment to evidence based practice as demonstrated by use of ICSI guidelines and evidence driven protocols.

Designated Medical Spine Specialist – is a clinician with a specialty in Physical Medicine.

    1. Focus On Therapeutic Outcomes (FOTO) - a physical functional status score. This measure is used to assess functional status of patients who received outpatient rehabilitation through the use of self-report health status questionnaires. Measures are taken at intake, during, and at discharge from rehabilitation to assess changes in functional status. Measure results are available in Outcomes Profile Reports, which provide 1) information for clinicians to help direct and improve the care of their patients in real time during treatment, and once treatments are complete, 2) a comparison of the clinician's or facility's outcomes and the National Aggregate in the FOTO® Database.

Kyphosis - A posterior curvature of the thoracic spine usually the result of a disease (lung disease, Paget's disease) or a congenital problem.

Oswestry Disability Index (ODI) - a commonly used outcome-measure questionnaire for low back pain. It is a self-administered questionnaire divided into ten sections designed to assess limitations of various activities of daily living. Each section is scored on a 0–5 scale, 5 representing the greatest disability. The index is calculated by dividing the summed score by the total possible score, which is then multiplied by 100 and expressed as a percentage.

Scoliosis – a congenital lateral curvature of the spine

Spinal Stenosis - An abnormal narrowing of the spinal canal that may be either congenital or acquired. Treatment is generally surgical to widen the spinal canal. Laminectomy may be the indicated surgical procedure to reduce pressure on the spinal cord.

Spondylolisthesis - Forward movement of one building block of the spine (vertebra) in relation to an adjacent vertebra.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The following CPT codes require prior authorization EXCEPT for the ICD 10 CM diagnosis codes listed below:

Codes

Description

22533

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22534

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)

22558

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22585

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

22612

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)

22614

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

22630

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

22632

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

22633

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

22634

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22800

Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

22802

Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

22804

Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments

22808

Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

22810

Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

22812

Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

22840

Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation)

22841

Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary - procedure)

22842

Posterior segmental instrumentation (e.g., pedicle screw fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments

22843

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments

22844

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments

22851

Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace

22899

Unlisted procedure, spine

0195T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace

0196T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure)

0309T

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure)

The following ICD-10 CM Codes do NOT require prior authorization:

Codes

Description

A17.81

Tuberculoma of brain and spinal cord

A18.01

Tuberculosis of spine

B90.2

Sequelae of tuberculosis of bones and joints

C41.2

Malignant neoplasm of vertebral column

C70.1

Malignant neoplasm of spinal meninges

C79.31, C79.32

Secondary malignant neoplasm of brain and cerebral meninges

C79.40, C79.49

Secondary malignant neoplasm of other and unspecified parts of nervous system

C79.51, C79.52

Secondary malignant neoplasm of bone and bone marrow

D33.4

Benign neoplasm of spinal cord

D32.1

Benign neoplasm of spinal meninges

D43.0-D43.2, D43.4

Neoplasm of uncertain behavior of brain and central nervous system

D42.0-D42.9

Neoplasm of uncertain behavior of meninges

D48.0

Neoplasm of uncertain behavior of bone and articular cartilage

G83.4

Cauda equina syndrome

G83.9

Paralytic syndrome, unspecified

M08.08, M45.0-M45.9, M48.8X1-M48.8X9

Rheumatoid arthritis/ankylosing spondylitis

M24.80

Other specific joint derangements of unspecified joint, not elsewhere classified

M25.28

Flail joint, other site

M53.2X1-M53.2X9

Spinal instabilities

M51.9

Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder

M51.06

Intervertebral disc disorders with myelopathy, lumbar region

M43.27, M43.28

Fusion of spine, lumbosacral & sacrococcygeal regions

M53.2X7, M53.2X8

Spinal instabilities, lumbar, sacral & sacrococcygeal regions

M53.3

Sacrococcygeal disorders, not elsewhere classified

M53.86-M53.88

Other specified dorsopathies, lumbar, lumbosacral, sacral & sacrococcygeal regions

M48.50XA-M48.58XS, M80.08XA-M80.08XS, M80.88XA-M80.88XS, M84.58XA-M84.58XS

Pathologic fracture of vertebrae

M80.00XP, M80.08XP, M80.80XP, M80.88XP, M84.30XP, M84.40XP, M84.48XP, M84.50XP, M84.58XP, M84.60XP, M84.68XP

Malunion of fracture

M80.00XK, M80.08XK, M80.80XK, M80.88XK, M84.30XK, M84.40XK, M84.48XK, M84.50XK, M84.58XK, M84.60XK, M84.68XK

Nonunion of fracture

M40.00-M40.05

Postural kyphosis

M41.00-M41.35, M96.5

Kyphoscoliosis and scoliosis

S12.000A-S12.691B, S12.9XXA-S12.9XXD, S22.000A-S22.089B, S32.000A-S32.059B, S32.10XA-S32.19XB, S32.2XXA-S32.2XXB

Fracture of vertebral column without mention of spinal cord injury

S32.009A, S32.019A, S32.029A, S32.039A, S32.049A, S32.059A, S34.101A-S34.129S

Closed fracture of lumbar spine with spinal cord injury

S32.009B, S32.019B, S32.029B, S32.039B, S32.049B, S32.059B, S34.101A-S34.129S

Open fracture of lumbar spine with spinal cord injury

S31.000A, S33.101A

Open dislocation, lumbar vertebra

The following ICD-10- CM Diagnoses DO require prior authorization. This list is not all inclusive.

Codes

Description

M47.20, M47.819, M47.899, M47.9

Spondylosis of unspecified site without mention of myelopathy

M51.26, M51.27

Other intervertebral disc displacement, lumbar & lumbosacral regions

M51.36, M51.37

Other intervertebral disc degeneration, lumbar & lumbosacral regions

M96.1

Postlaminectomy syndrome, not elsewhere classified

M48.06, M48.07, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73

Spinal stenosis of lumbar region

M54.5

Low back pain (lumbago)

M41.80-M41.9

Other forms of scoliosis

M43.8X9

Other specified deforming dorsopathies, site unspecified

M40.10-M40.15

Other secondary kyphosis

M40.50-M40.57

Lordosis, unspecified

M41.40-M41.57

Neuromuscular scoliosis & Other secondary scoliosis

M43.00-M43.19

Spondylosis and spondylolisthesis

Q76.2

Congenital spondylolisthesis

Q76.411-Q76.419, Q76.49

Other congenital malformations of spine, not associated with scoliosis

9.13, S33.0XXA, S33.100A-S33.141S

Closed dislocation, lumbar vertebra

Diagnosis Codes that are not associated with the scope of this policy & do not require prior authorization, include but is not limited to:

Codes

Description

M47.21-M47.23, M47.811-M47.813, M47.891-M47.893

Cervical spondylosis without myelopathy

M47.011-M47.029, M47.11-M47.13

Cervical spondylosis with myelopathy

M47.24, M47.25, M47.814, M47.815, M47.894, M47.895

Thoracic spondylosis without myelopathy

M47.14, M47.15

Thoracic spondylosis with myelopathy

M50.20-M50.23

Other cervical disc displacement

M51.24, M51.25

Other intervertebral disc displacement, thoracic & thoracolumbar regions

M50.30-M50.33

Other cervical disc degeneration

M51.34, M51.35

Other intervertebral disc degeneration, thoracic & thoracolumbar regions

M50.00-M50.03

Cervical disc disorder with myelopathy

M51.04, M51.05

Intervertebral disc disorders with myelopathy, thoracic & thoracolumbar regions

M99.12, S23.100A-S23.171S

Subluxation and dislocation of thoracic vertebra

S23.101A-S23.101S

Dislocation of unspecified thoracic vertebra, initial encounter

S14.0XXA-S14.108S, S14.111A-S14.118S, S14.121A-S14.128S, S14.131A-S14.138S, S14.141A-S14.148S, S14.151A-S14.158S

Cervical spinal cord injury without evidence of spinal bone injury

S24.0XXA-S24.104S, S24.111A-S24.114S, S24.131A-S24.134S, S24.141A-S24.144S, S24.151A-S24.154S

Thoracic spinal cord injury without evidence of spinal bone injury

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.